/ / Last Name First Name Middle Name MO / DA / YEAR Date of Birth ( ) ONSET: When did your most recent episode of pain begin? Lifting Pushing Pulling

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1 Sports & Spine Physicians Personal Health History (To be completed by patient) / / MO / DA / YEAR Today s Date / / Last Name First Name Middle Name MO / DA / YEAR Date of Birth ( ) Referral Source Telephone Number Dominant Hand: R L Age: _ Sex: M F ONSET: When did your most recent episode of pain begin? How did the current episode of pain occur? (check all that apply) Gradual onset Fall Direct blow Reaching Twisting Bending Was your injury the result of one of the following? Vehicle accident Recreational accident / / MO / DA / YEAR Lifting Pushing Pulling On-the-job injury Non-work-related accident Don t know Other: No known cause If your injury was work-related, what is your L&I or Workers Compensation claim number? Please briefly describe the onset of your pain and the events that preceded the onset: Do you find this injury was your employer s or another person s fault? Yes No Place EPIC Label Within Box PERSONAL HEALTH HISTORY - SSP PAGE OF 2

2 CURRENT STATUS: Using any or all of the symbols from the box on the right, mark the areas on the drawings below where you now feel your typical pain. Include all affected areas. SYMBOLS: Ache: >>>>> Pins & Needles oooooo Numbness: = = = = Stabbing: /////////// Left Right Right Left Right Left Right Left R L R L Do you have back or leg pain? No Yes If yes, please answer the following 3 questions:. Which is worse, your back pain or your leg pain? back pain leg pain about equal 2. Do you often have just back pain without leg pain? Yes No 3. Do you often have just leg pain without back pain? Yes No Do you have neck or arm pain? No Yes If yes, please answer the following 3 questions:. Which is worse, your neck pain or your arm pain? neck pain arm pain about equal 2. Do you often have just neck pain without arm pain? Yes No 3. Do you often have just arm pain without neck pain? Yes No In the last week, how many days did you have your usual pain? Circle one number: In the last week, during an average day, how much of the time were you in pain because of your back/neck/joint problems? Check one box: Less than hour per day Between and 4 hours per day Between 4 and 8 hours per day Almost any time I was awake Almost 24 hours per day and night Check the worst and best times for your pain: WORST BEST If you have NIGHT pain, does it: First awakening First awakening Prevent you from falling asleep? Morning Morning Awaken you at night? Afternoon Afternoon Hurt worse when lying down at night Evening Evening than during the day? Night time Night time What do each of the following activities do to your pain? PAGE 2 OF 2

3 After how long No Change Relieves Pain Increases Pain of that activity? Sitting Walking Standing Lying down Bending forward Bending backward Lifting Coughing/sneezing Changing positions What do you do to relieve your pain? ) 3) _ 2) 4) _ PAIN INTENSITY (Please circle one number for each Pain as bad question.) No Pain as could be How intense is your pain right now? In the PAST WEEK, how intense was your WORST pain? In the PAST WEEK, how would you rate your LEAST pain? In the PAST WEEK, how would you rate your AVERAGE pain? How would you describe your overall severity of pain over the past few months? Minimal pain Moderate; I am having difficulty dealing with it Mild, but can live with it Severe, it is ruining my quality of life PROGRESSION: How is your current back/neck/joint pain, compared to when this pain episode first started? Much improved Somewhat improved No change A little worse Much worse N/A How is your current leg/arm pain, compared to when this pain episode started? Much improved Somewhat improved No change A little worse Much worse N/A How much change do you expect in your pain 6 months from now? Worse No change Somewhat improved Much improved Total relief PAGE 3 OF 2

4 CURRENT FUNCTION: When your back / neck / joint hurts, you may find it difficult to do some of the things you normally do. This list contains some sentences that people have used to describe themselves when they have back / neck / joint pain. When you read them, you may find that some stand out because they describe you TODAY. As you read the list, think of yourself TODAY. When you read a sentence that describes you TODAY, put an X next to it. If the sentence does not describe you, then leave the space blank and go on to the next one. Remember, only X the sentence if you are sure that it describes you TODAY. ) I stay at home most of the time because of my back / neck / joint. 2) I change position frequently to try and get my back / neck / joint comfortable. 3) I walk more slowly than usual because of my back / neck / joint. 4) Because of my back / neck / joint, I am not doing any of the jobs that I usually do around the house. 5) Because of my back / neck / joint, I use a handrail to get up stairs. 6) Because of my back / neck / joint, I lie down to rest more often. 7) Because of my back / neck / joint, I have to hold on to something to get out of an easy chair. 8) Because of my back / neck / joint, I try to get other people to do things for me. 9) I get dressed more slowly than usual because of my back / neck / joint. 0) I only stand for short periods of time because of my back / neck / joint. ) Because of my back / neck / joint, I try not to bend or kneel down. 2) I find it difficult to get out of a chair because of my back / neck / joint. 3) My back / neck / joint is painful almost all the time. 4) I find it difficult to turn over in bed because of my back / neck / joint pain. 5) My appetite is not very good because of my back / neck / joint pain. 6) I have trouble putting on my socks (or stockings) because of the pain in my back / neck / joint. 7) I only walk short distances because of my back / neck / joint. 8) I sleep less well because of my back / neck / joint. 9) Because of my back / neck / joint pain, I get dressed with help from someone else. 20) I sit down for most of the day because of my back / neck / joint. 2) I avoid heavy jobs around the house because of my back / neck / joint. 22) Because of my back / neck / joint pain, I am more irritable and bad tempered with people than usual. 23) Because of my back / neck / joint, I go up stairs more slowly than usual. 24) I stay in bed most of the time because of my back / neck / joint. What are some of your usual recreational activities that you participated in the YEAR BEFORE your current problem? Place an X in front of those you currently cannot perform: ( ) _ ( ) ( ) _ ( ) ( ) _ ( ) How often do you have to stop your activities and sit down or lie down to control your pain? Never Occasionally Approximately once per day Several times per day I spend almost all day lying or sitting to control my pain PAGE 4 OF 2

5 DIAGNOSTIC TESTS: Which of the following diagnostic tests have been done on your back/neck? Please indicate date for yes answers. Approximate Approximate Workup No Yes Date Workup No Yes Date Regular x-rays Bone scan MRI scan Discogram _ CT scan EMG / SSEP Myelogram Bone density Other _ TREATMENTS: Please list the physicians, chiropractors, osteopaths and/or physical therapists you have seen within the LAST YEAR for your back / neck / joint pain, along with the approximate dates. Provider Name Type of Provider Address Approximate Dates _ Put an X next to each treatment you have had for your back / neck / joint pain in the past or currently. For each treatment you have had, circle Yes or No in each column. Treatment Effect of Treatment Currently Using? Helped? Made symptoms worse? Home exercise program Yes No Yes No Yes No Bed rest Yes No Yes No Yes No Hot packs / ice Yes No Yes No Yes No TENS unit for home use Yes No Yes No Yes No Back brace Yes No Yes No Yes No Physical therapy Yes No Yes No Yes No Massage Yes No Yes No Yes No Chiropractic treatment Yes No Yes No Yes No Osteopathic manipulation Yes No Yes No Yes No Acupuncture Yes No Yes No Yes No Epidural injections Yes No Yes No Yes No Facet injections Yes No Yes No Yes No Local (trigger point) injections Yes No Yes No Yes No Joint injections Yes No Yes No Yes No Other Yes No Yes No Yes No PAGE 5 OF 2

6 Have you ever received care from a mental health professional? Yes No If yes, briefly explain: Are you receiving mental health care for your current pain problem? Yes No If yes, briefly explain: PREVIOUS BACK/NECK/JOINT HISTORY: Have you had any previous back/neck/joint symptoms (other than the current problem) severe enough to seek professional help? Yes No _ Just those mentioned above If yes, how long ago and briefly explain: Were any of these previous episodes the result of a job injury or motor vehicle accident? Yes No If yes, please explain: Please list approximate dates off work for more than two weeks due to these previous injuries: Were you compensated for any of the above injuries via disability coverage (e.g., workers compensation) or a legal settlement? Yes No If yes, please explain: Including this current episode, about how many episodes of back/neck/joint pain have you had within the last two years that have been severe enough to see a physician? If you have had surgery on your back/neck (including chymopapain), please fill in the following for each operation: Pain After Surgery: Date Type of Surgery & Surgeon Worse Same Better (MD Use Only) SLEEP: Have you had any of these sleep problems at least half the days of the past month? Trouble falling asleep when you first go to bed _ Yes No Waking up during the night and not easily going back to sleep _ Yes No Waking up in the morning earlier than planned or desired _ Yes No Feeling unsatisfied or not rested by your night s sleep _ Yes No Feeling excessively sleepy during the day (does not include regular naps) _ Yes No How many hours per night do you sleep currently, on average? Did your sleep problems exist prior to your current pain problem? _ Yes No _No sleep problems now PAGE 6 OF 2

7 GENERAL HEALTH HISTORY: Who is your primary care physician? Name: Phone: ( ) Address: When was your last complete checkup?. Have you ever had a heart attack? No Yes 2. Have you ever been treated for heart failure (the doctor may have told you that you No Yes had fluid in your lungs or that your heart was not pumping well)? 3. Have you had an operation to unclog or bypass the arteries in your legs? No Yes 4. Have you had a stroke, cerebrovascular accident, blood clot or bleeding in the brain, or transient ischemic attack (TIA)? No Yes 4a. Do you have difficulty moving an arm or leg as a result of a stroke or cerebrovascular accident? No Yes 5. Do you have asthma? No Yes If yes, do you take medications for your asthma? No Yes, only with asthma flare-ups Yes, regularly 6. Do you have emphysema, chronic bronchitis, or chronic obstructive lung disease? No Yes If yes, do you take medications for it? No Yes, only with flare-ups Yes, regularly 7. Do you have stomach ulcers or peptic ulcer disease? No Yes 8. Do you have diabetes (high blood sugar)? No Yes 9. Has the diabetes caused problems with your kidneys, eyes, or skin? No Yes 0. Have you ever had problems with your kidneys (high creatinine, dialysis, transplant)? No Yes. Do you have rheumatoid arthritis or lupus? No Yes If yes, do you take medications regularly for it? No Yes 2. Do you have Alzheimer s disease or another form of dementia? No Yes 3. Do you have hepatitis, cirrhosis, or serious liver damage? No Yes 4. Do you have leukemia or polycythemia vera? No Yes 5. Do you have lymphoma? No Yes 6. Do you have cancer, other than skin cancer, leukemia, or lymphoma? No Yes 7. Do you have AIDS/HIV? No Yes 8. Have you ever had problems with bleeding or blood clots? No Yes 9. Do you have any chronic persistent/bothersome pain in any other parts of your No Yes body? 20. Do you have any other bone/joint problems? No Yes PAGE 7 OF 2

8 Do you have any other current medical or pain problems? _ No _ Yes If yes, please list: ) 4) 2) 5) 3) 6) Please list any non-back / neck / joint surgeries you have had and the approximate date of each one: ) 4) 2) 5) 3) 6) REVIEW OF SYSTEMS: Please put an X next to any of the symptoms you have had during the past year: Unexplained fevers Coughing up blood Night sweats Swollen ankles Chills Stomach pain Unintended weight loss of 0 Nausea/vomiting lb. or more Change in bowel habits Loss of appetite Excessive constipation Excessive fatigue Persistent diarrhea Problem with depression Dark black stools Unusual stress at work life Blood in stools Easy bruising Pain or burning when urinating Excessive bleeding Difficulty urinating (starting or Any lumps in neck, armpits stopping) or groin Blood in urine Chest pain or tightness Need to urinate more at night Persistent or unusual cough Need to urinate more often Trouble breathing with exercise Urinary urgency Trouble breathing lying flat Please explain any symptoms marked: Loss of bladder control or accidents Problems with sexual function Loss of sensation around the groin or buttocks Generalized morning stiffness Persistent eye redness Muscle tenderness Dry eyes or mouth Skin rashes Joint pain or swelling. List joints: Anemia Loss of balance Dizziness Gait disturbance WOMEN ONLY (please put an X next to any of the following that apply): Vaginal bleeding other than at the time of your menstrual period Pap smear within the last 2 years Currently having painful menstrual periods that interfere with usual work or activities Back pain increases with menstrual periods Pregnant or possibly pregnant Perform monthly breast self-exam Mammogram within the last 2 years Date of last pelvic exam: Take over 000 mg of calcium daily Pap smear normal? _ Yes _ No PAGE 8 OF 2

9 MEDICATIONS: List all medications (prescription and non-prescription) that you are currently taking. Put a (star) next to the ones you are taking for your back / neck / joint. How long have you Reason for Medication Dosage/Frequency been taking this? taking: ALLERGIES: Please list allergies to medications or other allergies. Name of Medication Reaction Other Allergies (e.g., food, pollen, latex) Reaction If more space is needed, please list on a separate sheet. FAMILY HISTORY: Living? Age or age at death Present health or cause of death Father Yes No Mother Yes No Brothers #Living #Deceased Sisters #Living #Deceased Children #Living #Deceased Significant medical conditions in other family members: PAGE 9 OF 2

10 SOCIAL HISTORY: Habits: Have you ever smoked? No Yes Age began: Check all that apply: Cigarettes Cigars Pipe During the time you smoke(d), indicate the average number of cigarettes smoked daily: less than pack per day pack per day _ to 2 packs per day _ more than 2 packs per day If you ve quit smoking, at what age? How often do you have a drink containing alcohol? Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking? _ or 2 _ 3 or 4 _ 5 or 6 _ 7 to 9 _ 0 or more How often do you have six or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Have you ever used alcohol to control your pain? Yes No Mood: (Check one box on each line.) How much time during the past four weeks All of the time Most of the time Some of the time A little of the time None of the time Have you been very nervous? Have you felt so down in the dumps that nothing could cheer you up? Have you felt calm and peaceful? Have you been happy? Over the last two weeks, how often have you Several More than Nearly been bothered by any of the following problems? Not at all days half the days every day Little interest or pleasure in doing things Feeling down, depressed, or hopeless Education: How much have you completed? Less than high school Graduated from high school/ged Vocational School Some college Graduated from college Post graduate degree Marital status: What is your current marital status? Never married Living with significant other Married Separated Divorced Widowed Stress: Have you had a stress or change in a significant relationship within the past 2 months? No Yes If yes, explain briefly: Have you ever considered yourself a victim of physical, emotional, or sexual abuse? No Language: Are you fluent in English? Yes No Other language: Yes PAGE 0 OF 2

11 OCCUPATIONAL HISTORY: Employer: Date of Hire: Usual occupation: Briefly describe your job: How physically demanding is your job? Very heavy (frequently lifting > 50 pounds) Light (frequently lifting < 0 pounds) Heavy (frequently lifting pounds) Sedentary (essentially no lifting) Moderate (frequently lifting 0-25 pounds) Work status at the time of onset of this episode of back / neck / joint pain: Permanent disability (pension, SSDI) Retired Regular: full time Not currently in workforce/homemaker/student Regular: part time On public assistance Working, modified job (e.g., light duty) Unemployed, looking for work Temporary disability (e.g., workers compensation) Work status today: Permanent disability (pension, SSDI) Retired Regular: full time Not currently in workforce/homemaker/student Regular: part time On public assistance Working, modified job (e.g., light duty) Unemployed, looking for work Temporary disability (e.g., workers compensation) How satisfied are you with your job? Very satisfied Satisfied Dissatisfied It is the worst job I ve ever had _ N/A If your back / neck / joint got completely better during the next few weeks, do you think your employer would let you return to the job you had before this episode of back / neck / joint pain? Yes Probably Doubt it Definitely not N/A Is your employer able and willing to offer you job accommodations (e.g., light duty, part-time work, flexible schedule, special equipment) if needed to allow you to work? Yes No N/A How certain are you that you will be working in 6 months? (Circle one) N/A Not at all Extremely Work not relevant certain certain Are you planning to apply for Social Security Disability (SSDI) or other disability (e.g., workers compensation)? _ Yes _ No Has your employer treated you fairly? Yes No N/A If no, please explain: _ Has anyone in your family been on disability coverage? Yes No If yes, what is their relationship to you? _Yes _No Is a lawyer helping you with a claim or lawsuit related to your current pain or other symptoms? If yes, explain briefly: PAGE OF 2

12 DEMOGRAPHICS: What is your race? American Indian/Alaskan Native Asian Black/African-American Native Hawaiian/Pacific Islander White/Caucasian Other/Unknown More than one race What is your ethnicity? Hispanic/Latino Not Hispanic/Latino Please sign and date this form: PATIENT SIGNATURE PRINT DATE PHYSICIAN SIGNATURE PRINT PAGER UPIN/NPI DATE TIME MD USE ONLY Right Left Left Right PAGE 2 OF 2